For Médecins Sans Frontières, an organization that has specialized in responding to emergencies as well as working in fragile and unpredictable contexts, no two years are the same. There is of course the ongoing work carried out by our thousands of staff around the world, who provide healthcare where it’s lacking and deal with diseases that continue to take a high toll on populations. But over and beyond the more constant medical activity, each year brings new challenges to our organization.

Two worrying developments stand out for 2009: the dwindling commitment of donor bodies for continuing the battle against HIV/ AIDS and a sharp increase of security incidents that affect our ability to bring assistance. In 2009, we started looking closely at the funding for HIV/AIDS in eight African countries. A clear pattern is starting to show of donor backtracking on earlier, widely publicized commitments to scale up the fight against the epidemic. The effects on availability and level of care for those infected are becoming clear in countries where we work. In some countries where infection rates for HIV/AIDS are high, patients are turned away from clinics, and clinicians are once again being forced into the unacceptable position of rationing life-saving treatment. MSF will emphasize the unacceptable nature of this withdrawal in appropriate private and public forums throughout 2010.

In conflict areas, where MSF is often one of very few providers of healthcare, our ability to assist has been put under immense pressure with a string of extreme security incidents. In February, two of our colleagues were brutally killed in Pakistan’s Swat Valley, as they were trying to collect wounded people by ambulance from the scene of heavy fighting. Nasar Ali and Riaz Ahmad were known and admired for their dedication to the health and survival of others, but tragically paid the ultimate price for this.

In 2009, MSF workers were abducted in Pakistan, Sudan, Somalia and Chad. Luckily, we saw all of them released in good health. But if humanitarian workers are not safe from violence, the organization that employs them faces tough questions. For MSF, our determination to be with the victims of conflict has not diminished – if anything, it has only grown – but we are forced to continuously evaluate how to bring lifesaving assistance in areas where our colleagues are so exposed to acts of violence.

A situation of war creates victims in a variety of ways. There are the direct victims, those that our surgical teams help and support. And then there are hidden victims. The impact of conflicts and subsequent mass displacement, on often precarious pre-existing health systems, is in most cases disastrous. It generally stimulates a dramatic rise of maternal and child fatalities or an eruption of epidemics. Victims of sexual violence and survivors affected by profound mental health traumas are also among the hidden casualties of war, and our medical teams assist them with a sense of urgency in many different countries.

The military offensives in the Palestinian Territories left 1,300 people dead, 5,300 injured and an entire population dependent on medical aid and relief. We had a team on the ground before the offensive was launched – we have been offering mental health support for years in the Gaza Strip – but it was only when the offensive was put on hold that a complete MSF surgical team was allowed to enter Gaza City, despite our repeated efforts to enter earlier. We then set up two inflatable hospitals, and between January and July performed over 500 operations. Meanwhile, the psychological toll of the fighting was especially heavy on children. Additional MSF staff were brought in to help with consultations; more than half of the 400 new patients they saw for counseling were under 12 years old.

In the Democratic Republic of the Congo (DRC), ongoing conflict continues to cause huge critical needs, prompting one of MSF’s largest interventions year after year. Again, we try to carry out a full range of medical activities there in the midst of what has become a chronic health emergency. MSF carried out 530,000 medical consultations in 2009, vaccinated 650,000 children against measles and cared for 5,600 rape victims in North and South Kivu.

In conflict-ridden Afghanistan in 2009, the deadliest year for civilians since the war began in 2001, we resumed our medical work after a five-year absence following the deliberate killings of five of our colleagues in 2004. Our immediate preoccupation, both in Kabul and in the province of Helmand, was to offer medical assistance to the general population rather than only focusing on war wounded. In Mardan, Pakistan, where around one million displaced people settled, having fled fighting in the Swat district, our teams supported referral hospitals, health centers and mobile clinics.

Our ability to bring care to people trapped in conflict is sometimes restricted by policies and actions of governments. In Sudan, providing food, water and health care for people in Darfur became much more difficult in March 2009 when the Sudanese authorities expelled 13 international aid agencies – including two sections of MSF—and three Sudanese organizations in the wake of the International Criminal Court’s indictment of Sudanese President Omar Al-Bashir for war crimes and crimes against humanity.

The decision by the government effectively meant that not only MSF but also the needs of the population of Darfur were held hostage to political and judicial agendas. It also ignored MSF’s binding and publicly communicated policy to refrain from any cooperation with the aforementioned Court, a policy based on the recognition that humanitarian activities must remain independent from political and judicial pressure in order to be able to provide medical assistance to populations in situations of violence. Today more than ever, it seems that we must relentlessly explain the principles of neutrality, impartiality and independence that guide our choices as a humanitarian organization.

The conflict in Sri Lanka came to a climax, leaving many civilians in a vulnerable state as they tried to reach safe zones, but they all too often found themselves trapped by the violence. Access to medical facilities and aid was extremely difficult. More often than not, by the time they finally reached those who could help them, their health needs were critical.

Our work extends way beyond the conflict areas described above. In 2009, MSF organized large-scale immunization campaigns, particularly against meningitis in western Africa, where we vaccinated almost eight million people in both Nigeria and Niger. Our teams intervened after major natural disasters throughout the year, by providing medical and mental health care, as well as shelter and other logistical support. Likewise we helped 150,000 people made homeless by floods in the Burkina Faso capital of Ouagadougou, in September, when the amount of rain that usually falls in a year fell in one single day. And other teams assisted 75,000 people hit by Cyclone Aila in Bangladesh, and 60,000 flood victims in India’s Andhra Pradesh.

Our contribution towards reducing the HIV/AIDS and TB epidemics continued unabated. In 2009 over 190,000 people were being treated by MSF for HIV, and some 160,000 were on antiretroviral treatment. Many of these patients live remotely, have little money, and under normal circumstances would not receive medical care. But MSF continued to address this lack of access to treatment where possible. Teams offered testing and counseling, provided ART free of charge, reduced rates of transmission from mother to child and trained ‘expert patients’ often HIV patients themselves, to help others adhere to treatment. For example in Lesotho alone, 54,000 HIV tests were carried out and 6,000 patients began ART.

TB, which has become the leading cause of death among HIV patients, is also a growing concern for MSF: failure to adhere to the difficult course of treatment for TB can lead to drug-resistant strains of the disease developing, and these are even more problematic to treat, especially if the patient’s immune system is already compromised by HIV. MSF is working hard to combine the treatment of HIV and TB in resource poor settings to try and reverse this trend. In 2009 MSF treated over 21,000 TB patients.

A number of neglected diseases are still not getting the international attention they require. Three in particular - sleeping sickness, Kala Azar and Chagas leave more than 500 million people at risk from infection. In response, in 2009 MSF committed 18 million Euros over the next six years to a joint initiative with the Drugs for Neglected Diseases initiative (DNDi) for continued research into critically needed new drugs to treat these diseases more effectively. MSF will also continue to provide support through its field programs to the operational and clinical research needed to advance drug development. In 2009 MSF treated over 6,000 patients for these three diseases.

The neglected needs of migrants remain among our most pressing concerns. Migrants undergo journeys fraught with danger and uncertainty, and when they arrive – if they arrive – their health often continues to be compromised. Some are held for long periods in overcrowded detention camps; some are forced to live hidden away from the authorities, where their undocumented status makes it impossible for them to access basic care. MSF offers such people free medical and mental health consultations, protecting their identity where possible and referring them when necessary to local hospitals.

We give medical assistance at different stages of their journey. In countries of origin, such as Somalia, Afghanistan, DRC and Nigeria, we treat the medical consequences of violence and deprivation. In Morocco, Greece, Malta, Italy and France, our teams provide medical and psychological care to those who survived the journey; many migrants and asylum seekers are subjected to violence and abuse, are imprisoned and exploited or fall victim to smugglers and traffickers.

We equally assist migrants outside Europe. Many refugees and asylum seekers from the Horn of Africa seek safety in Yemen. The harsh conditions of the trip and sea accidents cause hundreds of deaths, and the state of health of those who do manage to reach the Yemeni coast is often poor. Around 9,000 people received medical assistance from MSF in Abyan and Shabwah governorates in the south of the country in 2009.

In Bangladesh, many thousands of Rohingya refugees from neighboring Myanmar face a daily struggle to survive. Out of an estimated population of up to 400,000 Rohingya who have fled across the border, only 28,000 are recognized as official refugees by the government and accordingly entitled to assistance by UNHCR. MSF set up an emergency healthcare project to help 20,000 unrecognized Rohingya refugees living in harsh conditions in Kutupalong makeshift camp.

Just outside the scope of this reporting period, early 2010 saw the launch of the largest emergency operation in MSF history following the devastating earthquake that ruined large parts of Haiti and claimed many thousands of lives. Within the first four months MSF teams assisted 173,000 patients and performed more than 11,000 surgeries.

This tragedy has stretched our organization and forced us into a difficult balancing act of staging such a massive and urgent emergency relief effort while fully retaining our commitment to the health and lives of people in many other parts of the world. Together with the need to mobilize donors for their continued support to reverse the HIV/AIDS epidemic, and the growing concern about increased violence against humanitarian workers, Haiti will set the tone for 2010.

The continued contribution of millions by people around the world who support MSF financially is key to our ability to bring medical assistance to those who need it urgently, and for keeping interference from political, military or economic agendas at bay. We are immensely grateful to all donors who make MSF’s work in over 65 countries possible.